Saving Face: Facebook for Physicians

Social media has been transformed from an adolescent pastime to a medium that reaches every type of place and all types of people. (1)

In six years, the membership of Facebook skyrocketed from students at Harvard University to 500 million people across the world. Users spend 700 billion minutes on Facebook each month, and nearly 150 million people access Facebook on their mobile devices. (2)

The social media movement has also intrigued many physicians. A survey of 1,800 physicians done by Manhattan Research found that 60 percent of doctors regularly visit social networking web sites, or they are interested in joining one. Also, health care organizations benefit from social media through recruitment, building relationships in the community, and customer satisfaction. (3, 4)

Despite this, some physicians are uncertain about Facebook, and are hesitant to participate. Part of this is "because professional standards of care are unclear" for using Facebook in a health care setting. (5)

This article will examine ways physicians might benefit from using Facebook as a communication tool in their medical practice, as well as strategies to avoid some potential pitfalls.

BENEFITS TO PHYSICIANS AND PATIENTS

The potential benefits of Facebook include:

strengthening the physician/patient relationship;

keeping patients informed/engaging in dialogue;

increasing the physician's referral base; and

securing job opportunities through social networking with colleagues.

"Quality health care requires a physician-patient dialogue that doesn't simply end once the physician leaves the examining room. While online standards of care need to be established by professional medical societies, in the meantime, physicians should embrace social media as a way to continue the conversation, and to provide patients with the trusted health information they'll need," says Kevin Pho, MD, creator of the medical blog Kevin MD. (5)

Patients are already taking advantage of the creative ways health care providers use social media. Emergency departments are displaying wait times and keeping family members updated on their loved-ones' progress. The CDC uses Facebook to keep people informed about public health events such as H1N1. Physicians can post Facebook updates about new medical studies for patients to read. (5)

Now that patients routinely search the Internet for answers to their health care questions, social media is playing an even bigger role. "There are thousands of blogs and Facebook groups where patients discuss their experiences living with cancer, HIV, or depression. Fifty-seven million Americans reading blogs, combined with 120 million monthly U.S. visitors to Facebook and Twitter, social media presents a compelling opportunity for doctors to interact with patients." (5)

Facebook can help physicians increase their referral base. "We use social media to identify people; we also use it as a way to develop people we work with," says Jamey Morgan, president of Concorde Staff Source, a physician staffing firm. "For example, if we're working with a doctor who has done work for us on the temporary side, and we are really happy with the doctor and the clients are happy with the doctor, we're going to trust their recommendations." (6)

Physicians have also taken advantage of the numerous opportunities for professional networking, allowing them to socialize with colleagues around the world. These connections help physicians in their job searches. (6)

The Mayo Clinic employs Facebook to engage patients, using the site to educate patients with discussions and videos about health care issues. The Mayo Clinic Facebook page — with nearly 24,000 fans — provides physicians with training, consulting, and speaking services, designed to make them more able to help patients and meet their needs. "Mayo Clinic believes individuals have the right and responsibility to advocate for their own health, and that it is our responsibility to help them use social media tools to get the best information, connect with providers and with each other, and inspire healthy choices." (7, 8)

CAUTIONS AND CAVEATS

While Facebook offers opportunities, it also presents challenges to physicians. These include:

maintaining boundaries;

accuracy of information;

time required to keep pages current;

security of information; and

loss of nonverbal cues.

Catherine Roush, medical director for the Woman's Group in Tampa, explains that physicians in her group struggle "with how to handle patients on Facebook. Colleagues are faced with difficult decisions." Physicians do not want to offend patients by ignoring them on Facebook, but they do not want to cross boundaries. (9)

In an article from the Chicago Tribune, Sachin Jain, MD adds that he did not want patients to see his personal photos or read his personal blog. Neither did he want to snub patients. "The anxiety I felt about crossing boundaries is an old problem in clinical medicine, but it has taken a different shape as it has migrated to this new medium." (10)

Another potential problem for Facebook is one that already plagues the Internet — inaccurate medical information. According to an article in the New England Journal of Medicine, "Once you land on a site that asserts a false rumor as truth, hyperlinks direct you to further sites that reinforce the falsehood." Many unconfirmed cures have been circulated on the web such as claims that macrobiotic diets cure lymphoma; hyperbaric oxygen treats AIDS; and milk thistle treats chronic hepatitis. Untruths could spread on Facebook, and physicians will be the ones who have to disprove harmful information brought to them by their patients. (11)

The time required to maintain a Facebook page can also be a challenge to physicians. Dr. Jain, who is a resident physician at Brigham and Women's Hospital, has hesitantly accepted patients as friends on his personal Facebook page. He wonders — is he expected to take the time to be available 24/7 to those patients? (12)

Dr. Jain also worries about the security of Facebook and whether it opens him up to HIPAA violations and litigation. (13) "Take, for example, the MICU nurse who blogs about her experiences in dealing with a difficult patient, forgetting that one of the patient's family members has access to her blog. Or the dermatology resident who is asked on a date by a clinic patient after he learns from her online profile that she is single — information that he would have hesitated to draw out of her in person. Although many web sites allow users to choose higher privacy settings and to control which personal content is available to whom, it is clear that there is no longer a professional remove between many clinicians and their patients." (1) (For more information about the ethical issues of physician-patient relationships, please see the article "Crossing professional boundaries.")

While Facebook is a great communication tool, conversations on the site are one-dimensional. "It's impossible to judge the effect on patients of information transmitted through cyberspace: we can't observe grimaces, tears, or looks of uncertainty. And written dialogue is quite different from spoken conversation: replies may be delayed, phrases may be more stilted, tone of voice is absent. We should pay close attention to any unintentional fraying of the physician—patient bond." (11)

GUIDELINES USED BY PHYSICIANS

"Because few have looked at social media's impact on patient care, there is little guidance on how physicians can incorporate it into their medical practice," says Dr. Pho. With no "official" guidelines, physicians wishing to use Facebook can look to other physicians who have successfully employed it.

Health care blogger and Houston pediatric gastroenterologist, Bryan Vartabedian, MD suggests the following "pointers" for physicians who are contacted by patients through social media.

"Take the discussion offline. All dialogue concerning attempts at online contact are done by phone or in person.

Understand they're just looking for help. Keep in mind that when patients try to reach you via Facebook they're just looking for help. Twitter and Facebook are now becoming standard means of interaction so why would it be so strange to contact your doctor? In my dialogue with patients who have crossed the line I try to approach the issue in a way that respects where they're coming from.

Give them the facts. While I'm not a lawyer, I do my very best to discuss the importance of online health privacy. Social media is for casual conversation, not privileged health information. While we will likely see the proliferation of secure social media platforms for doctor-patient communication in the future, we're not there yet.

Remind them you'll get in trouble. When I remind parents (of patients) that they're going to get me in trouble, they feel bad. I don't want to make anyone feel bad, but they have to understand the potential gravity of the situation when it comes to the law, state licensing bodies, and hospital privacy.

Point out why social media represents a risky means of communication. After detailing how I could find myself in hot water, I then try to illustrate how social media isn't built for patient care (emphasis mine). Among other things it's not easy to follow what happens between a practitioner and patient on a social application. Who said what or, more importantly, was the intended plan even understood by the patient? And how do you and other members of the health care team refer to a plan of care? Very high tech but very sloppy.

Document everything. Any attempt by my patients to discuss clinical matters via Twitter or other platforms is immediately documented in the patient's medical record. I also document that I have discussed with the patient or family the appropriate ways to contact me.

Make a social media policy of your own. One way to keep your patients from reaching out to you online is by creating an office social media policy of your own. Rules of engagement via social media should be just as important as on call or billing procedures. Along those lines I occasionally post friendly online reminders that public discussion of care with health professionals isn't appropriate. I keep a few clipped screen shots of these posts in the event that my social media judgment is ever called into question.

Block repeat offenders. Patients who don't understand the importance of health privacy represent a risk to themselves and a major liability to you. Offer one warning and block after that. As physicians we have the responsibility to help patients understand what isn't always obvious. And teaching the pitfalls of online health dialogue fit with that responsibility." (13)

ADDITIONAL GUIDELINES

Disclaimers
Physicians are strongly urged to post a disclaimer on their Facebook sites. The Mayo Clinic displays a short but direct disclaimer that states "Mayo Clinic reserves the right to remove posts advertising commercial products, as well as those that violate Facebook's terms of service, or are inaccurate or otherwise objectionable." (14)

Personal/Private Facebook pages

Madelyn Butler, executive director of the Florida Medical Association says, "You never mix the professional and personal with Facebook because you don't have any privacy and those are two lines that should not be crossed." (9)

Whether or not to "friend" a patient

This is a special area of concern for physicians, and there is no shortage of opinions on what physicians should do. "Be very careful when 'friending' a patient. A patient, for example, may post on a physician's Facebook wall about chest pain, and the physician may only check Facebook once a week. This is bad for both the patient and the physician," says Steve Levine, vice president of communication at Texas Medical Association.

In her article "A doctor's request: please don't 'friend' me," Katherine Chretien, MD states, "Having a so-called dual relationship with a patient — that is, a financial, social or professional relationship in addition to the therapeutic relationship — can lead to serious ethical issues and potentially impair professional judgment. We need professional boundaries to do our job well. For these reasons, if you add me as your friend on Facebook, I will have to politely decline. Because I like you. Because I love being your doctor. And, because some lines shouldn't be crossed." (15)

Other physicians believe that there are ways to appropriately "friend" patients. "The easiest way to avoid this problem is to have two separate Facebook accounts: a professional/patient account and a private/personal account. Any Facebook user should be familiar with the privacy settings on Facebook. These can be customized. For example, you might create groups called 'patients', 'relatives' and 'close personal friends'; assigning different permissions to each of these groups." (16)

Another way to avoid "friend" problems on Facebook is to create a fan page. "A fan page can be a good way to interact with patients, market your practice, and discuss health care policy," says Steve Levine. According to a recent article in American Medical News, "Anyone on Facebook who elects to 'become a fan' of your page receives, on his or her own home page, any updates, photos, videos or web links that you post. Rather than having patients 'friend' you on Facebook, you can direct them to the fan page." (17)

Privacy

Physicians should be very cautious when posting any identifiable information about patients. Likewise, they should be cautious with any information they post about themselves. Physicians should "populate their site only with professional information, such as area of specialty, office address, academic affiliation and contact information." (18)

Physicians can use Facebook privacy settings to their advantage. Choose conservative privacy settings to control access to profiles. "Physicians must be aware of their privacy settings on Facebook. In the past, the site has changed its default privacy settings. This is bad for physicians since they rely on good privacy settings to be able to confidently use Facebook," says Steve Levine. "Therefore, privacy settings should be checked regularly."

CONCLUSION

"Remember, Facebook and social media are a new world of information. Online conversations are a great way to communicate, but senders lose some of the control they once had with traditional, one-way communication," says Steve Levine.

Physicians who decide to integrate Facebook into their practices should remember that, with caution and boundaries, Facebook can be an effective way to interact with colleagues and patients. However, Facebook is still relatively new, and many experts have recommended a slow and restrained approach.

For more information on Facebook and social media for physicians, please see TMA's social media resource center.